IMPORTANCE End-of-life care costs are high and decedents often experience poor quality of care. Numerous factors influence changes in site of death, health care transitions, and burdensome patterns of care.OBJECTIVE To describe changes in site of death and patterns of care among Medicare decedents.

OBJECTIVES To examine family member's perceptions of decision-making and outcomes of feeding tubes. DESIGN Mortality follow-back survey. Sample weights were used to account for oversampling and survey design. A multivariate model examined the association between feeding tube use and overall quality of care rating regarding the last week of life. SETTING Nursing homes, hospitals, and assisted living facilities. PARTICIPANTS Respondents whose relative had died from dementia in five states with varying feeding tube use. MEASUREMENTS Respondents were asked about discussions, decision-making, and outcomes related to their loved ones’ feeding problems. RESULTS Of 486 family members surveyed, representing 9,652 relatives dying from dementia, 10.8% reported that the decedent had a feeding tube, 17.6% made a decision not to use a feeding tube, and 71.6% reported that there was no decision about feeding tubes. Of respondents for decedents with a feeding tube, 13.7% stated that there was no discussion about feeding tube insertion, and 41.6% reported a discussion that was shorter than 15 minutes. The risks associated with feeding tube insertion were not discussed in one-third of the cases, 51.8% felt that the healthcare provider was strongly in favor of feeding tube insertion, and 12.6% felt pressured by the physician to insert a feeding tube. The decedent was often physically (25.9%) or pharmacologically restrained (29.2%). Respondents whose loved ones died with a feeding tube were less likely to report excellent end-of-life care (adjusted odds ratio = 0.42, 95% confidence interval = 0.18–0.97) than those who were not. CONCLUSION Based on the perceptions of bereaved family members, important opportunities exist to improve decision-making in feeding tube insertion.

No abstract

Objectives-To inform efforts aimed at reducing Medicare hospice expenditures by describing the longitudinal use of hospice care in nursing homes (NHs) and examining how hospice provider growth is associated with use.Design-Longitudinal study using NH resident assessment (MDS) and Medicare denominator and claims data for years 1999 through 2006. Setting-Nursing homes in the 50 U.S. states and District of ColumbiaParticipants-Persons dying in U.S. NHs Measurements-We identified Medicare beneficiaries dying in NHs, receipt of NH hospice, and lengths of hospice stay. We also identified the number of hospices providing care in NHs and used a panel data fixed-effect (within) regression analysis to examine how growth in providers affected hospice use. Conclusion-Policy efforts to curb Medicare hospice expenditures (driven in part by provider growth) must consider the potentially negative impact of changes on access for dying (mostly noncancer) NH residents. Results-Between

BACKGROUND/OBJECTIVES To evaluate how receipt and timing of nursing home (NH) palliative care consults (primarily by nurse practitioners with palliative care expertise) is associated with end-of-life care transitions and acute care use DESIGN A propensity-score (pscore) matched retrospective cohort study SETTING Forty-six NHs in two states PARTICIPANTS NH residents who died in 2006–2010 stratified by days between initial consult and death: ≤7, 8–30, 31–60 or 61–180. By strata, pscore matching identified three controls (n=1,174) for each consult recipient (n=477). MEASUREMENTS Outcomes were hospitalizations in the last 7, 30 and 60 days of life, emergency room visits in the last 30 and 60 days, and any potentially burdensome care transition defined as hospitalization or hospice admission within three days of death or two or more hospitalizations or emergency room visits within 30. Weighted multivariate logistic regression analyses evaluated outcomes. RESULTS Residents with consults (compared to controls) had lower rates of hospitalization, with rates lowest when initial consults were furthest from death. For instance, among residents with initial consults 8–30 days before death the adjusted hospitalization rate in the last seven days of life was 11.1% (95% CI, 9.79 to 12.43) compared to 22.0% (95% CI, 20.62 to 23.41) among controls; however, among those with initial consults 61–180 days before death, rates were 6.9% (95% CI, 5.47 to 8.37) compared to 22.9% (95% CI, 20.48 to 25.42). Potentially burdensome transition rates were lower when consults were 61–180 days before death (16.2% (95% CI, 13.74 to 18.57) compared to 28.2% (95% CI, 25.82 to 30.59)) for controls. CONCLUSION Findings suggest palliative care consults improve end-of-life NH care by reducing acute care use and potentially burdensome care transitions.

Objectives This study examined life stage differences in the provision of care to spouses with functional impairment. Methods We examined 1218 married adults aged 52 and older from the 2000 wave of the Health and Retirement Study (HRS) who received impairment-related help with at least one activity of daily living. We examined the differential likelihood that spouses serve as primary caregiver and the hours of care provided by spousal primary caregivers by life stage. Results We found that late middle-aged care recipients were more likely than their older counterparts to receive the majority of their care from their spouse, but received fewer hours of spousal care, mostly when spouses worked full time. Competing demands of caring for children or parents did not affect the amount of care provided by a spouse. Discussion Late middle-aged adults with functional limitations are more likely than older groups to be married and cared for primarily by spouses; however they may be particularly vulnerable to unmet need for care. As the baby boom generation ages, retirement ages increase, and federal safety nets weaken, people with health problems at older ages may soon find themselves in the same caregiving predicament as those in late middle age.

The present study demonstrates that the characteristics of groups reporting inadequate care versus no care, and the factors associated with these situations, are quite different. Nevertheless, the most important demographic risk factors for both types of unmet need mirror demographic groups currently on the increase in the U.S. population.

Objectives To understand whether nursing home (NH) introduction of culture change practices is associated with improved quality Design NH-level panel study using multivariate fixed-effects statistical modeling to estimate the effect of culture change introduction on quality outcomes Setting and Participants 824 U.S. NHs with culture change practice involvement beginning between 2005 and 2010 Measurements A culture change practice score (derived from a 2009/10 national NH survey) was used to stratify analyses by NHs with high practice implementation (scores in the top quartile; n=217) versus other NHs (n=607). NH-level outcomes included 1) prevalence of seven care practices and three resident outcomes; 2) a NH’s health-related and quality-of-life weighted survey deficiencies; and, 3) the average number of hospitalizations per resident year. Results For NHs with high practice implementation, introduction of culture change was associated with a significant decrease in the prevalence of restraints, tube feeding and pressure ulcers; an increase in the proportion of residents on bladder training programs; and, a small decrease in the average number of hospitalizations per resident year (coefficient −0.04, standard error (SE) 0.022; p=0.06). For NHs having lower practice implementation (practice scores in lower-three quartiles), introduction was associated with fewer health-related (coefficient −5.26; SE 3.05; p=0.09) and quality-of-life (coefficient −0.10; SE 0.049; p=0.04) survey deficiencies. However, these NHs also had small statistically significant increases in the prevalence of residents with urinary tract infections and in the average hospitalizations per resident year (coefficient 0.03; SE 0.014; p=0.02). Conclusion The introduction of NH culture change appears to result in significant improvements in some care processes and outcomes in NHs having high practice implementation. For other NHs, culture change introduction results in fewer survey deficiencies.